Access Keys Skip to Menu Skip to Content Skip to Footer

8.5 Medical, Surgical Issues

Diabetes mellitus

Breastfeeding and diabetes have a close relationship - breastfeeding has an impact on pre-existing and potential diabetes and diabetes has a impact on breastfeeding. Lactation may be delayed or impaired for reasons both of diabetes and obesity, so women in the diabetic spectrum need special consideration and attention to breastfeeding and lactation assistance.

Gestational diabetes mellitus (GD)

  • mothers who had GD and suppress lactation have higher serum glucose than had they breastfed
  • suppressing lactation has an immediate detrimental effect on their glucose tolerance and lasting effects on maternal metabolic profiles 1
  • mothers who had GD and suppress lactation will significantly increase their risk of developing Type 2 diabetes 1 2
Type 2 diabetes mellitus
  • Being artificially fed in infancy is associated with an increased risk of Type 2 diabetes. 3
  • Due to their decreased glucose metabolism and altered metabolic profiles women who suppress lactation do not receive the protection that delays or prevents Type 2 diabetes mellitus in women who breastfeed their babies.
  • Being obese and suppressing lactation significantly increases the risk of developing Type 2 diabetes mellitus. 2
Type 1 diabetes mellitus
  • Onset of secretory activation (lactogenesis II) may be delayed. 4
  • Being artificially fed as an infant significantly increases the risk of developing Type 1 diabetes mellitus. 5 6 7
  • Glucose use increases during lactation; lactating mothers can reduce their insulin by 25% or more of pre-pregnancy dose, while increasing their carbohydrate intake. Insulin requirements of mothers who suppress lactation is greater. 8 9 10

Impact on lactation

  • women who are diabetic are more likely to birth preterm, have a caesarean section or assisted birth and experience other obstetric complications, all of which increase the risk of lactation difficulty
  • mothers who are diabetics are more likely to NOT breastfeed or have a shorter breastfeeding duration 11
  • separation of mother and baby is more likely due to preterm birth, Caesarean section and blood glucose testing
  • maternal diabetes delays the onset of lactogenesis II 12
  • in some units the baby is at greater risk of being given artificial infant formula, causing various breastfeeding difficulties

Recommendations

It is unfortunate that mothers with diabetes are at increased risk of breastfeeding difficulties which not only impacts on their own health but also on the health of their child who then becomes at risk of developing the same diabetic condition.

For the present and future health of the mother with diabetes and her baby:

  • provide education about the effects of artificially feeding on herself and her baby
  • suggest prenatal expressing of breastmilk; give infant the milk prophylactically during first day
  • encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding
  • support measures to establish milk supply if mother and infant separated or infant not able to latch

In light of the increased risk to the health of this woman and her child practices which interfere with breastfeeding, such as separation and giving artificial infant formula should be reviewed.

Maternal overweight and obesity

Obesity is a risk factor for diabetes. Both impact on breastfeeding.
  • being artificially-fed correlates to obesity in childhood and adulthood 13 14 15
  • overweight and obesity increases obstetric complications and is associated with a greater risk of operative delivery

  • mothers who artifically feed compared to those who breastfeed (>6 months) have

    • a 2 kg greater weight gain by 1 year postpartum
    • larger waist girth
    • greater weight gain 10-15 years later

  • Lactation difficulty
    • lactogenesis II may be delayed 16
    • positioning the baby to facilitate good latching is more difficult
    • the greater the BMI the greater the risk of early cessation of breastfeeding compared to women with normal BMI
    • overweight and obese women are less likely to plan to breastfeed, initiate breastfeeding and wean earlier 17

Recommendations

Give additional education and support to breastfeed to overweight and obese mothers -

  • encourage skin-to-skin contact after birth, early initiation and frequent breastfeeding
  • support measures to establish milk supply if mother and infant separated or infant not able to latch
  • assistance with positioning infant could include using the underarm hold, raising their breast on a pillow or using a rolled up cloth or towel under the breast, and using a mirror to allow them to view their infant latching correctly to their breast.

Social measures that increase breastfeeding will result in less overweight and obese adults. Pre-conception education should provide help for women to achieve a normal BMI before pregnancy.

Urgently needed are qualitative studies from women's perspective to help us understand women in this situation and their infant feeding decisions and behaviour.

Thyroid disease

Autoimmune thyroid dysfunctions are a common cause of both hyper- and hypo-thyroidism.

Graves' disease (hyperthyroid) and postpartum thyroiditis are two major causes of thyrotoxicosis in the postpartum period. Antithyroid drugs, propylthiouracil or methimazole, are the mainstay of the treatment of postpartum thyrotoxicosis and both are safe to take while breastfeeding. Radioiodine treatment is contraindicated during lactation. 18

There is a relatively high prevalence of hypothyroidism, especially subclinical hypothyroidism. Hypothyroidism is associated with insufficient breastmilk supply and may be one of the symptoms which alerts you to this condition. Thyroxine replacement therapy is safe for the breastfeeding baby and milk levels will improve once the mother becomes euthyroid.

Thyroid status varies considerably postpartum. Medication dosage may need adjusting during the postpartum months. Be mindful of symptoms such as fatigue, palpitations, weight loss, loss of concentration and depression. Facilitate medical review of the mother.

Recommendations

All women with diagnosed thyroid disease should have their therapy re-evaluated frequently during pregnancy and lactation and medication dosage adjusted as necessary. This is particularly necessary for women who are being treated for hypothyroidism because of the impact on breastmilk sufficiency.

Evaluate all mothers who have breastmilk insufficiency for hypothyroidism.

Hepatitis

Hepatitis B (HBV)
With appropriate immunoprophylaxis, including hepatitis B immune globulin and hepatitis B vaccine, breastfeeding does not contribute to mother-to-child transfer of HBV. 19 20
Prior to vaccination, concern of transmission of HBV via cracked nipples was speculated but not recorded.

Hepatitis C (HCV)
There is no evidence of mother-to-infant transmission of hepatitis C from breastfeeding.

Recommendations

Women who are hepatitis B or C positive should be encouraged to breastfeed their babies.

Workbook Activity 8.10

Complete Activity 8.10 in your workbook.

HIV

About 5-15% (1 in 20, to 1 in 7) of babies born to women who are HIV infected will become HIV-positive through breastfeeding. This means most infants born to women who are HIV-positive will not be infected through breastfeeding.
Exclusive breastfeeding reduces the risk of transfer by about half for HIV +ve mothers. Artificial feeding damages the gut allowing transfer of the virus.
Note: Before giving a supplement to ANY breastfed baby consider the risk you are submitting the baby to should the mother unknowingly be HIV positive.

WHO Recommendations for infant feeding

When the mother is HIV negative OR her status is unknown
  • exclusive breastfeeding for the first 6 months, then
  • introduce complementary foods while continuing to breastfeed for 24 months and beyond.
When the mother is HIV positive
  • commence anti-retroviral therapy (ARV) during pregnancy and continue for the duration of breastfeeding
  • infants to receive ARV therapy
  • exclusive breastfeeding for 6 months, then
  • introduce complementary foods while continuing to breastfeed for 24 months and beyond
  • continue ARV therapy for the duration of breastfeeding. 21

HIV and NOT breastfeeding

Safe alternatives to exclusive breastfeeding are heat-treated mother's own breastmilk,22 donor breastmilk from a safe source, or artificial infant formula.
Support the mother in her choice of infant feeding, ensuring that whatever she chooses is as safe as possible.

Issues to discuss with the mother who is NOT breastfeeding:

  • What are the replacement feeding options and which, if any, are acceptable, feasible, affordable, sustainable and safe in her situation;
  • What she will need in order to use the method she chooses - source of milk, water, equipment, cost, time.
  • If artificial infant formula is used, the difference between types of formula and what types are suitable for her infant;
  • If a home-prepared recipe is used, what are the available sources of milk and whether they are suitable and safe?
  • Is the household water supply accessible and safe? If it is not safe, what water can the mother use?
  • Water will need to be boiled to mix formula, and hot water is needed for pasteurizing her breastmilk and washing the equipment. Is there fuel available?
  • How will she keep the equipment clean?
  • Who will help her learn to prepare her chosen method and when will she learn these things?

Workbook Activity 8.11

Complete Activity 8.11 in your workbook.

Unfortunately most HIV-infected women do not have the resources for safe replacement feeding. Breastfeeding, though not exclusive breastfeeding, is the cultural norm in those countries most affected by HIV. It has been found that adherence to feeding intention among HIV-infected women was higher in those who chose to exclusively breastfeed than those who replacement feed.23

In a study in Botswana24, breastfeeding with zidovudine prophylaxis was not as effective as formula feeding in preventing postnatal HIV transmission, but was associated with a lower mortality rate at 7 months. Both breastfed and artificially-fed had comparable HIV-free survival at 18 months.

Breast surgery

Reduction mammoplasty surgery which has involved severing large numbers of lactiferous ducts, removal of large amounts of glandular tissue, or severing the 4th intercostal nerve innervating the nipple/areola, will affect breastfeeding ability to varying degrees. (The 4th intercostal nerve is the stimulus for the milk ejection reflex, some severed ducts will re-anastomose)

Breast augmentation also has the potential to negatively affect breastfeeding because of severed 4th intercostal nerve and ducts with peri-areola incision method, and compression of glandular tissue with sub-glandular placement of implant.

Breastfeeding, milk transfer and the baby's condition should be closely monitored to ensure the baby continues to thrive. An antenatal consultation with a Lactation Consultant followed by close supervision of initial and ongoing breastfeeding management and early interventions to increase supply is important.

Breastfeeding and medication usage

Some women need to take medications while breastfeeding. It is important to ensure the baby will not be harmed via breastmilk transfer of the medication. It is equally as important not to forfeit breastfeeding when there are safe, effective medications. In most cases, it is far preferable to continue breastfeeding with small amounts of drug present in milk rather than risk many more hazardous effects of infant formula feeding.

All medications transfer into breastmilk to some degree but very, very few medications are contraindicated during breastfeeding. As a general rule of thumb less than 1% of the maternal dose passes via the breastmilk to the baby. Up to 10% of maternal dose is usually considered to be safe. 25

Several factors influence the ultimate medication dose which the infant will receive via breastmilk:

  • the transfer of the drug into the breastmilk - influenced by specific drug properties such as maternal drug level reached, molecular weight, protein binding capacity.
  • the uptake of the drug by the infant from the breastmilk - daily intake of infant, stomach acidity, gut absorption.

Everyone who prescribes medications for breastfeeding women should have access to a recent text that specifically reviews medications for mothers. This is the link to an excellent online resource. Externalhttp://toxnet.nlm.nih.gov/cgi-bin/sis/htmlgen?LACT . Bookmark this resource for future reference.

The known detrimental effect of artificial infant formula feeding for both mother and baby needs to be seriously considered prior to ceasing breastfeeding due to maternal medication use. An alternative drug should be sought if the one usually prescribed is contraindicated.

What should I remember?

  • The important cause/effect cycle of each type of diabetes and breastfeeding.
  • The important cause/effect cycle of obesity and breastfeeding.
  • How thyroid conditions may impact on breastfeeding.
  • That HBV and HCV infection is not a contraindication for breastfeeding.
  • Exclusive breastfeeding for 6 months reduces risk of HIV mother-to-child transfer.
  • The WHO guidelines for HIV and infant feeding.
  • What type of breast surgery may impact on breastfeeding and why.
  • Most medications are safe to continue with breastfeeding and if not, a safe alternate can be found.

Self-test quiz

Match an item from the column on the left with an item from the column on the right. Click on an item in one column, then on its matching response from the other column

Assessment Quiz

When you are happy that you've understood all the information in this topic you will be ready to complete the Module 8 Assessment. To do this, go to the course opening page, scroll down to the Assessment section and choose Module 8.

Notes

  1. # Kjos SL et al. (1993) The effect of lactation on glucose and lipid metabolism in women with recent gestational diabetes
  2. # Gunderson EP (2007) Breastfeeding after gestational diabetes pregnancy: subsequent obesity and type 2 diabetes in women and their offspring
  3. # Das UN (2007) Breastfeeding prevents type 2 diabetes mellitus: but, how and why?
  4. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
  5. # Rosenbauer J et al. (2007) Early nutrition and risk of Type 1 diabetes mellitus - a nationwide case-control study in preschool children.
  6. # Malcova H et al. (2006) Absence of breast-feeding is associated with the risk of type 1 diabetes: a case-control study in a population with rapidly increasing incidence
  7. # Tenconi MT et al. (2007) Major childhood infectious diseases and other determinants associated with type 1 diabetes: a case-control study
  8. # Illingworth P et al. (1989) Insulin requirements during breast feeding
  9. # Davies HA et al. (1989) Insulin requirements of diabetic women who breast feed
  10. # Riviello C et al. (2009) Breastfeeding and the basal insulin requirement in type 1 diabetic women.
  11. # Hummel S et al. (2008) [Breastfeeding in women with gestational diabetes]
  12. # Hartmann P et al. (2001) Lactogenesis and the effects of insulin-dependent diabetes mellitus and prematurity
  13. # von Kries R et al. (1999) Breast feeding and obesity: cross sectional study.
  14. # Kalies H et al. (2005) The effect of breastfeeding on weight gain in infants: results of a birth cohort study
  15. # Harder T et al. (2005) Duration of breastfeeding and risk of overweight: a meta-analysis
  16. # Rasmussen KM et al. (2004) Prepregnant overweight and obesity diminish the prolactin response to suckling in the first week postpartum.
  17. # Amir LH et al. (2007) A systematic review of maternal obesity and breastfeeding intention, initiation and duration
  18. # Azizi F (2003) Thyroid function in breast-fed infants is not affected by methimazole-induced maternal hypothyroidism: results of a retrospective study
  19. # Hill JB et al. (2002) Risk of hepatitis B transmission in breast-fed infants of chronic hepatitis B carriers
  20. # Zhongjie Shi (2011) Breastfeeding of newborns by mothers carrying Hepatitis B virus
  21. # World Health Organisation and UNICEF (2010) HIV and infant feeding
  22. # Israel-Ballard K et al. (2007) Flash-heat inactivation of HIV-1 in human milk: a potential method to reduce postnatal transmission in developing countries.
  23. # Bland RM et al. (2007) Infant feeding counselling for HIV-infected and uninfected women: appropriateness of choice and practice
  24. # Thior I et al. (2006) Breastfeeding plus infant zidovudine prophylaxis for 6 months vs formula feeding plus infant zidovudine for 1 month to reduce mother-to-child HIV transmission in Botswana: a randomized trial: the Mashi Study
  25. # Hale T (2010) Medications and Mothers Milk